National Antimicrobial Prescribing Survey Research Articles

The feasibility and generalizability of assessing the appropriateness of antimicrobial prescribing in hospitals: a review of the Australian National Antimicrobial Prescribing Survey.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing practices. Since its release in 2013, the NAPS has been adopted by all hospital types within Australia, including public and private facilities, and supports them in meeting the national standards for accreditation. Hospitals can generate real-time reports to assist with local antimicrobial stewardship (AMS) activities and interventions. De-identified aggregate data from the NAPS are also submitted to the Antimicrobial Use and Resistance in Australia surveillance system, for national reporting purposes, and to strengthen national AMS strategies. With the successful implementation of the programme within Australia, the NAPS has now been adopted by countries with both well-resourced and resource-limited healthcare systems. We provide here a narrative review describing the experience of users utilizing the NAPS programme in Canada, Malaysia and Bhutan. We highlight the key barriers and facilitators to implementation and demonstrate that the NAPS methodology is feasible, generalizable and translatable to various settings and able to assist in initiatives to optimize the use of antimicrobials.

Impact of a mobile decision support tool on antimicrobial stewardship indicators in St. John's, Canada.

Inappropriate antibiotic use contributes to antimicrobial resistance. The SpectrumTM app provides antibiotic decision support, based on local antimicrobial resistance rates. We determined the impact of regional implementation of the app on inpatient antimicrobial appropriateness, inpatient antimicrobial usage (AMU), population-based Clostridioides difficile infection (CDI) rates and cost, using a retrospective, before and after quasi-experimental design, including a one-year study period. The SpectrumTM app was released to prescribers in February, 2019. We performed two one-day inpatient point prevalence surveys using the National Antimicrobial Prescribing Survey tool, six months before (June 25, 2018) and six months after (June 25, 2019) app dissemination. Inpatient AMU in Defined Daily Dose/1000 patient days and CDI incidence were compared, before and after app dissemination. The pre-survey included 184 prescriptions, and the post-survey included 197 prescriptions. Appropriateness was 97/176 (55.1%) pre, and 126/192 (65.6%) post (+10.5%, p = 0.051). Inpatient AMU declined by 6.6 DDD/1000 patient days per month, and CDI declined by 0.3 cases per month. Cost savings associated with reduced AMU were $403.98/bed/year and associated with reduced CDI were $82,078/year. We observed improvement in antimicrobial stewardship indicators following SpectrumTM implementation. We cannot determine the cause of these improvements.

Appropriateness of antibiotic use in community hospitals inrural Newfoundland and Labrador.

Surveillance of the appropriateness of antimicrobial prescribing can identify targets for quality improvement in antimicrobial stewardship. Our objective was to measure antibiotic prescription prevalence, indication, and appropriateness at three rural community hospitals in a 1-day point prevalence study. Inpatient antibiotic prescriptions given at three community hospitals on April 24, 2019 were provided by the hospital pharmacies. These prescriptions were analyzed using the Australian National Antimicrobial Prescribing Survey (NAPS) tool. Prescriptions were assessed by an infectious diseases physician and analyzed per prescription. Eighty prescriptions given to 58 inpatients were included. Antibiotic treatment prevalence was 58/120 beds (48.3%), and overall appropriateness was 37/80 prescriptions (46.3%). The most prescribed antibiotics were ceftriaxone (17 [21.3%]; 47.1% appropriate), piperacillin-tazobactam (10 [12.5%]; 10.0% appropriate), and moxifloxacin (9 [11.3%]; 0% appropriate). The most common indications were respiratory tract infections (36 [45.0%]; 36.1% appropriate), skin and soft tissue infections (14 [17.5%]; 78.6% appropriate), and urinary tract infections (9 [11.3%]; 11.1% appropriate). Of the 80 prescriptions, 50 (62.5%) documented an indication, and 71 (88.8%) documented a stop or review date. We observed a high treatment prevalence and low appropriateness. Overall appropriateness was lower than in urban hospitals.

Point Prevalence Survey of Antimicrobial Use in a Malaysian Tertiary Care University Hospital.

Antimicrobial resistance remains a significant public health issue, and to a greater extent, caused by the misuse of antimicrobials. Monitoring and benchmarking antimicrobial use is critical for the antimicrobial stewardship team to enhance prudent use of antimicrobial and curb antimicrobial resistance in healthcare settings. Employing a comprehensive and established tool, this study investigated the trends and compliance of antimicrobial prescribing in a tertiary care teaching hospital in Malaysia to identify potential target areas for quality improvement. A point prevalence survey method following the National Antimicrobial Prescribing Survey (NAPS) was used to collect detailed data on antimicrobial prescribing and assessed a set of quality indicators associated with antimicrobial use. The paper-based survey was conducted across 37 adult wards, which included all adult in-patients on the day of the survey to form the study population. Of 478 patients surveyed, 234 (49%) patients received at least one antimicrobial agent, with 357 antimicrobial prescriptions. The highest prevalence of antimicrobial use was within the ICU (80%). Agents used were mainly amoxicillin/β-lactamase inhibitor (14.8%), piperacillin/β-lactamase inhibitor (10.6%) and third-generation cephalosporin (ceftriaxone, 9.5%). Intravenous administration was ordered in 62.7% of prescriptions. Many antimicrobials were prescribed empirically (65.5%) and commonly prescribed for pneumonia (19.6%). The indications for antimicrobials were documented in the patients’ notes for 80% of the prescriptions; however, the rate of review/stop date recorded must be improved (33.3%). One-half of surgical antimicrobial prophylaxis was administered for more than 24 h. From 280 assessable prescriptions, 141 (50.4%) were compliant with guidelines. Treating specialties, administration route, class of antimicrobial, and the number of prescriptions per patient were contributing factors associated with compliance. On multivariate analysis, administering non-oral routes of antimicrobial administration, and single antimicrobial prescription prescribed per patient was independently associated with non-compliance. NAPS can produce robust baseline information and identifying targets for improvement in antimicrobial prescribing in reference to current AMS initiatives within the tertiary care teaching hospital. The findings underscore the necessity to expand the AMS efforts towards reinforcing compliance, documentation, improving surgical prophylaxis prescribing practices, and updating local antibiotic guidelines.

Topical antimicrobial prescribing patterns in residents of Australian aged-care facilities: use of a national point prevalence survey to identify opportunities for quality improvement

Australian residential aged care facilities (RACFs) are encouraged to participate in an annual Aged Care National Antimicrobial Prescribing Survey. This data source was analysed to describe patterns of topical antimicrobial prescribing and thereby provide insight into antimicrobial stewardship (AMS) changes that might be required. 2018 and 2019 survey data was analysed. The overall prevalence of the 52,431 audited residents (629 facilities) who were prescribed 1 or more topical antimicrobials was 2.9%. Of all prescribed antimicrobials (n=4899), 33.0% were for topical application. Most frequently prescribed topical antifungals were clotrimazole (85.3%) and miconazole (9.1%), and antibacterials chloramphenicol (64.1%) and mupirocin (21.8%). Tinea (38.3%) and conjunctivitis (23.8%) were the 2 most common indications. Topical antimicrobials were sometimes prescribed for pro re nata administration (38.8%) and greater than 6 months (11.3%). The review or stop date was not always documented (38.7%). To reduce the possibility of adverse consequences associated with antimicrobial use, antimicrobial stewardship programs in Australian residential aged care facilities should at least ensure mupirocin is appropriately used, first line antimicrobial therapy is prescribed for tinea, chloramphenicol is prescribed for conjunctivitis only if necessary, pro re nata orders for prescriptions are discouraged and to avoid prolonged duration of prescriptions, review or stop dates are always documented.

Prevalence of antibiotic allergy labels and their consequences in people presenting to a teaching hospital Emergency Department; a retrospective chart review.

Antibiotic allergy labels have a direct impact on individual patient care and on the consumption of broad-spectrum antibiotics. Our aim was to establish the prevalence of antibiotic allergies and to determine whether patients with documented antibiotic allergy labels received guideline concordant antimicrobial therapy. Additionally we wanted to evaluate the quality of allergy documentation in the medical record. Prospective audit of all patients presenting to the Emergency Department of an adult teaching hospital in Sydney over a 4 month period. Documented allergy labels, diagnoses, antibiotic administration and outcomes were recorded. Appropriateness of antibiotic choice was based on the Australian National Antimicrobial Prescribing Survey. 9.9% of presentations had at least one antibiotic allergy recorded. Significantly more women than men had antibiotic allergies documented. One third of patients with documented antibiotic allergies were prescibed inappropriate antibiotic therapy and some had significant adverse events. The documentation of antibiotic allergy labels and choice of antibiotic treatment can be significantly improved. Strategies to safely de-label people with documented allergies who are not truly allergic need to be implemented.

Adherence to antimicrobial prophylaxis guidelines in cardiac implantable electronic device procedures in two Australian teaching hospitals.

Objective This study investigated antibiotic prophylaxis (AP) guideline adherence and the cardiac implantable electronic device (CIED) infection rate in two major Australian public teaching hospitals. Methods In a retrospective observational study, the medical records of patients who underwent CIED procedures between January and December 2017 were reviewed (Hospital A, n = 400 procedures; Hospital B, n = 198 procedures). Adherence to AP guidelines was assessed regarding drug, dose, timing, route and frequency. Infection was identified using follow-up documentation. Results AP was administered in 582 of 598 procedures (97.3%). Full guideline adherence was observed in 33.9% of procedures (203/598) and differed significantly between Hospitals A and B (47.3% vs 7.1%, respectively; P < 0.001). Common reasons for non-adherence were the timing of administration (42.3% vs 60.6% non-adherent in Hospitals A and B, respectively; P < 0.001) and repeat dosing (19.3% vs 78.8% non-adherent in Hospitals A and B, respectively; P < 0.001). Twenty infections were identified over 626.6 patient-years of follow-up (mean (±s.d.) follow-up 1.0 ± 0.3 years). The infection rate was 3.19 per 100 patient-years (P = 0.99 between hospitals). Two devices were removed due to infection; no patients died from CIED infection. Conclusions Although the rate of serious CIED infection was low, there was evidence of highly variable and suboptimal antibiotic use, and potential overuse of AP. What is known about the topic? Previous Australian studies have revealed high rates of inappropriate surgical AP. CIED infections are potentially life threatening, but can be avoided through effective use of AP. However, prolonged durations of AP in this setting may also result in complications, including Clostridioides difficile infection. What does this paper add? This study, the first to our knowledge to focus specifically on adherence to Australian guidelines for AP in CIED procedures, highlighted several common issues between AP in this setting and surgical and procedural AP more broadly. 'Early' and 'late' dose administration and extended post-procedural AP were common. Only 34% of prescriptions fully adhered to the guidelines; practices varied significantly between the two hospitals. What are the implications for practitioners? There is a clear need for institution-specific antimicrobial stewardship strategies to optimise AP in CIED procedures, aligned with the Antimicrobial Stewardship Clinical Care Standard. Patients are being placed at potentially avoidable risk of both complications of extended durations of AP and CIED infection, although the rate of serious CIED infection was low. A standardised approach to surveillance of CIED infections and prospective multisite audits of AP in CIED procedures using a validated tool, such as the Surgical National Antimicrobial Prescribing Survey, are recommended to better inform evidence-based practice. Potential strategies to optimise guideline adherence include prescribing support in patients with immediate penicillin hypersensitivity or methicillin-resistant Staphylococcus aureus colonisation, optimising the in-patient location of drug administration to promote timely dosing, limiting inappropriate post-procedural prophylaxis and routine S. aureus screening and decolonisation.

From Little Things Big Things Grow: The Development of an Auditing Program to Assess the Quality of Antimicrobial Prescribing

Background: An important aspect of antimicrobial stewardship is the qualitative assessment of antimicrobial prescribing. Owing to lack of standardized tools and resources required to design, conduct and analyze qualitative audits, these assessments are rarely performed. Objective: We designed an audit tool that was appropriate for all Australian hospital types, suited to local user requirements and including an assessment of the appropriateness of antimicrobial prescribing. Methods: In 2011, a pilot survey was conducted in 32 Australian hospitals to assess the usability and generalizability of a qualitative audit tool. The tool was revised to reflect the respondents’ feedback. A second study was performed in 2012 in 85 hospitals. In 2013, following further feedback and refinement, an online auditing tool, the Hospital National Antimicrobial Prescribing Survey (NAPS), was developed. Early audits demonstrated that surgical prophylaxis had the highest rates of inappropriate prescribing. In 2016, the Surgical NAPS was developed to further investigate reasons for this, and the NAPS program was further expanded to audit antimicrobial prescribing practices in Australian aged-care homes (ie, the Aged Care NAPS). Results: Between January 1, 2013, and November 12, 2019, 523 Australian public and private hospitals (53.8%) utilized the Hospital NAPS; 215 (22.1%) have utilized the Surgical NAPS; and 774 of Australian aged-care homes (29.0%) have utilized the Aged Care NAPS. National reporting has identified key target areas for quality improvement initiatives at both local and national levels. The following initiatives have been outlined in 14 public reports: improved documentation; prolonged antimicrobial prophylaxis; compliance with prescribing guidelines; appropriateness of prescribing; access to evidence-based guidelines; and improved microbiology sampling. Conclusions: By utilizing the Plan-Do-Study-Act cycle for healthcare improvement and by involving end users in the design and evaluation, we have created a practical and relevant auditing program to assess both quantitative and qualitative aspects of antimicrobial prescribing in a wide range of settings. This voluntary program is now endorsed by the National Strategy for Antimicrobial Resistance Surveillance, partners with the Antimicrobial Use and Resistance in Australian Surveillance System, and is utilized by facilities to meet mandatory national accreditation standard requirements. With the success of the NAPS program in Australia, it has now been implemented in New Zealand, Canada, Malaysia, Fiji, and Bhutan, with plans for other countries to implement the program soon. Current research is being conducted to expand the program to include audits for family physicians, veterinarians, and remote indigenous communities, and for antifungal use.Disclosures: NoneFunding: None

A National Aged Care Infection and Antimicrobial Use Survey: A Three-Year Report

Background: Australia has ~2,700 aged-care homes and 180 multipurpose services. The annual Aged Care National Antimicrobial Prescribing Survey (AC NAPS), first pilot tested in 2015, is a surveillance tool that can be used in these facilities to monitor infections and antimicrobial use. It assists in identifying priorities for local and national infection control and antimicrobial stewardship interventions. Methods: Nurses or pharmacists collect point prevalence data using standardized data collection forms: (1) A facility form, completed by each participating facility, includes resident-level data fields (eg, number of residents present on the survey day). (2) An infection form is completed for residents with signs and/or symptoms of infection. (3) An antimicrobial form is completed for residents who are prescribed an antimicrobial. Results: Regarding prevalence,for those 31 facilities that participated annually, there was no significant change in either prevalence rate (Table 1). Regarding priority areas for improvement (2018 data only), 64.6% of prescriptions were for residents who did not have signs and/or symptoms of a suspected infection in the week prior to the antimicrobial start date. The most common clinical indications for prescriptions were skin soft-tissue and mucosal infection (18.3%), cystitis (16.0%) and pneumonia (9.4%). Cefalexin (20.3%), clotrimazole (19.0%), and chloramphenicol (7.0%) were the most commonly prescribed antimicrobials. Review or stop dates were not documented for 58.9% of prescriptions. Only 39.2% of antimicrobials were prescribed in the 7 days prior to the survey day; 28.3% were prescribed &gt;6 months prior. Furthermore, 36.3% of all prescriptions were for topical application. In addition, 19.0% of antimicrobials were prescribed for PRN (as needed) administration; most (94.4%) of these were for topical antimicrobials, most commonly clotrimazole (65.4%). Conclusions: The AC NAPS has identified infections and consistent patterns of antimicrobial use that may adversely affect the safety of care for Australian aged-care residents. Interventions are now being developed, implemented, and evaluated to address identified ‘priority areas for improvement.’Funding: NoneDisclosures: None

Appropriateness of Orthopedic Surgical Antimicrobial Prophylaxis Prescribing in Australia: Meaningful Metrics for Surgeons

Background: Orthopedic procedures are performed at high volumes in Australia. Thus, they are a commonly audited procedure group when measuring surgical antimicrobial prophylaxis (SAP) appropriateness and compliance in Australia and internationally. Recent analysis of the Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) revealed high rates of inappropriateness, both procedurally (39.5%) and postprocedurally (53.0%). Inappropriate use can lead to patient harm and further increases the risk of antimicrobial resistance (AMR). Identification of factors associated with inappropriate orthopedic SAP prescribing may support the development of antimicrobial stewardship (AMS) interventions that are tailored to the orthopedic surgical setting to improve SAP. Methods: Surgical NAPS has been available to all Australian hospitals to complete from 2016; it supports the assessment of SAP appropriateness. Appropriateness is a composite measure based on antibiotic choice, timing of administration, dose and duration, applying the standardized Surgical NAPS Appropriateness Assessment Guide. Logistic regression was used to identify hospital, patient, and surgical factors associated with appropriateness. Adjusted appropriateness (AA) was calculated by generating marginal means from the multivariable model and averaging across all available covariates. Significance for multivariable analysis was determined as P &lt; .05. Additional subanalyses were conducted on smaller subsets to calculate the AA for specific orthopedic procedures. Results: In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS from January 1, 2016, to April 15, 2019, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness for prescribed procedural doses (n = 3,978) was 64.7% and was lower for prescribed postprocedural doses (n = 2,731, 48.3%). When antimicrobials were not prescribed, appropriateness was higher procedurally (n = 350, 89.7%) and postprocedurally (n = 1,127, 97.8%). When SAP was indicated, the most common reasons for inappropriateness, when prophylaxis was indicated, were timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The AA of each orthopedic procedure group was low for procedural SAP, ranging from 54.1% for knee surgery to 74.1% for total knee joint replacement. The adjusted appropriateness of postprocedural prescriptions was also low, ranging from 40.7% for hand surgery to 68.7% for closed reduction fractures. Conclusions: Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness is meaningful for both orthopedic surgeons and AMS programs. Targeted quality improvement projects are needed for orthopedic surgical procedures and to study the engagement between orthopedic surgeons, AMS, and guideline developers to support optimization of antimicrobial use in the surgical setting.Funding: NoneDisclosures: None

Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery.

Surgical antimicrobial prophylaxis (SAP) is commonly administered in orthopedic procedures. Research regarding SAP appropriateness for specific orthopedic procedures is limited and is required to facilitate targeted orthopedic prescriber behavior change. To describe SAP prescribing and appropriateness for orthopedic procedures in Australian hospitals. Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) audits from January 1, 2016, to April 15, 2019, were analyzed. Logistic regression identified hospital, patient and surgical factors associated with appropriateness. Adjusted appropriateness was calculated from the multivariable model. Additional subanalyses were conducted on smaller subsets to calculate the adjusted appropriateness for specific orthopedic procedures. In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness was low, 58.0% (n = 3,894). This differed for prescribed procedural (n = 3,978, 64.7%) and postprocedural doses (n = 2,731, 48.3%). The most common reasons for inappropriateness, when prophylaxis was required, was timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The adjusted appropriateness of each orthopedic procedure group was low for procedural SAP (knee surgery, 54.1% to total knee joint replacement, 74.1%). The adjusted appropriateness for postprocedural prescription was also low (from hand surgery, 40.7%, to closed reduction fractures, 68.7%). Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness identifies targets for quality improvement and is meaningful for clinicians. Targeted quality improvement projects for orthopedic specialties need to be developed to support optimization of antimicrobial use.

Measuring antimicrobial prescribing quality in outpatient parenteral antimicrobial therapy (OPAT) services: development and evaluation of a dedicated national antimicrobial prescribing survey.

BackgroundAntimicrobial stewardship programmes are important in driving safety and quality of antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is a point-prevalence audit of inpatient antimicrobial prescribing in Australian hospitals.ObjectivesTo design and adapt the NAPS tool for use in the outpatient parenteral antimicrobial therapy (OPAT) and hospital-in-the-home (HITH) setting.MethodsAn inter-disciplinary working group with expertise in OPAT and HITH services was established to adapt the NAPS template for use in the OPAT setting—called HITH-NAPS. This was initially trialled in 5 HITH services, subsequently adapted following participant feedback, then offered nationally to 50 services in 2017.ResultsThere were 1154 prescriptions for 715 patients audited via the HITH-NAPS. The most common antimicrobials prescribed were cefazolin (22%), flucloxacillin (12%), piperacillin/tazobactam (10%) and ceftriaxone (10%). The most common infections treated were cellulitis (30%) and respiratory tract infections (14%). Eighty-seven percent of prescriptions were assessed as appropriate, 11% inappropriate and 2% not assessable. Prolonged durations of antimicrobials and unnecessarily broad-spectrum antibiotics were used in 9% of prescriptions.ConclusionsThe HITH-NAPS pilot project revealed that auditing of this type is feasible in HITH. It showed that antibiotic use in these HITH services was generally appropriate, but there are some areas for improvement. A national OPAT/HITH-NAPS can facilitate benchmarking between services, identify potentially inappropriate prescribing and help guide quality improvement.

Antimicrobial stewardship in remote primary healthcare across northern Australia.

BackgroundThe high burden of infectious disease and associated antimicrobial use likely contribute to the emergence of antimicrobial resistance in remote Australian Aboriginal communities. We aimed to develop and apply context-specific tools to audit antimicrobial use in the remote primary healthcare setting.MethodsWe adapted the General Practice version of the National Antimicrobial Prescribing Survey (GP NAPS) tool to audit antimicrobial use over 2–3 weeks in 15 remote primary healthcare clinics across the Kimberley region of Western Australia (03/2018–06/2018), Top End of the Northern Territory (08/2017–09/2017) and far north Queensland (05/2018–06/2018). At each clinic we reviewed consecutive clinic presentations until 30 presentations where antimicrobials had been used were included in the audit. Data recorded included the antimicrobials used, indications and treating health professional. We assessed the appropriateness of antimicrobial use and functionality of the tool.ResultsWe audited the use of 668 antimicrobials. Skin and soft tissue infections were the dominant treatment indications (WA: 35%; NT: 29%; QLD: 40%). Compared with other settings in Australia, narrow spectrum antimicrobials like benzathine benzylpenicillin were commonly given and the appropriateness of use was high (WA: 91%; NT: 82%; QLD: 65%). While the audit was informative, non-integration with practice software made the process manually intensive.ConclusionsPatterns of antimicrobial use in remote primary care are different from other settings in Australia. The adapted GP NAPS tool functioned well in this pilot study and has the potential for integration into clinical care. Regular stewardship audits would be facilitated by improved data extraction systems.

Factors associated with antimicrobial choice for surgical prophylaxis in Australia.

BackgroundCefazolin is the most commonly recommended antimicrobial for surgical antimicrobial prophylaxis (SAP). However, the Australian Surgical National Antimicrobial Prescribing Survey revealed a wide range of antimicrobials prescribed for SAP. Inappropriate use of broad-spectrum antimicrobials is associated with increased patient harm and is a posited driver for antimicrobial resistance.ObjectivesTo describe patient, hospital and surgical factors that are associated with appropriateness of the top five prescribed antimicrobials/antimicrobial classes for procedural SAP.MethodsAll procedures audited from 18 April 2016 to 15 April 2019 in the Surgical National Antimicrobial Prescribing Survey were included in the analysis. Estimated marginal means analyses accounted for a range of variables and calculated a rate of adjusted appropriateness (AA). Subanalyses of the top five audited antimicrobials/antimicrobial classes identified associations between variables and appropriateness.ResultsA total of 12 419 surgical episodes with 14 150 prescribed initial procedural doses were included for analysis. When procedural SAP was prescribed, appropriateness was low (57.7%). Allergy status, surgical procedure group and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third/fourth-generation cephalosporins. The use of broad-spectrum antimicrobials was the most common reason for inappropriate choice (67.9% of metronidazole to 83.3% of third/fourth-generation cephalosporin prescriptions).ConclusionsVarious factors influence appropriateness of procedural SAP choice. Identification of these factors provides targets for antimicrobial stewardship interventions, e.g. procedures where surgeons are regularly prescribing broad-spectrum SAP. These can be tailored to address local hospital prescribing practices.

Antibiotic prescribing in surgery: A clinically and socially complex problem in Australia.

Surgical prophylaxis is a common indication for antimicrobial use in Australian hospitals with demonstrated poor rates of appropriateness. Ongoing analysis of the Surgical National Antimicrobial Prescribing Survey and exploration of influences on antimicrobial prescribing decisions can help identify clinical and behavioural issues that contribute to problematic antimicrobial use. Triangulation of quantitative and qualitiatve data supports the development of surgical antimicrobial stewardship, i.e., quality improvement initiatives for the optimisation of surgical antimicrobial prophylaxis. Such initiatives should be developed and implemented at both local and national levels to ensure that they remain effective and sustainable.

Antibiotic prescribing in neonatal sepsis: an Australian nationwide survey

ObjectiveTo evaluate quality and variation in antibiotic prescribing for neonatal sepsis.DesignWe analysed prescribing in hospitalised neonates using the National Antimicrobial Prescribing Survey in Australian neonates from 1 January 2014 to...

The 2018 Aged Care National Antimicrobial Prescribing Survey: results show room for improvement.

SUMMARYThe annual Aged Care National Antimicrobial Prescribing Survey aims to identify local and national prescribing issues and guide antimicrobial stewardship goalsIn the 2018 point prevalence survey, medication charts of over 20,000 residents were reviewed from 407 participating facilities across AustraliaOn the day of the survey, almost 10% of residents were prescribed an antimicrobialNearly two-thirds of recently prescribed antimicrobials were for residents who had no documented signs or symptoms of infectionOver a quarter of antimicrobials had been prescribed for longer than six monthsIncomplete documentation was a prominent barrier to proper review of antimicrobial therapy, with the indication, review date or stop date not documented for many prescriptionsRecommendations include using appropriate microbiological testing to guide prescribing, following national antimicrobial prescribing guidelines, documenting the indication for the antimicrobial, and its start, stop and review dates, and monitoring and re-evaluating long-term antimicrobial use

Appropriateness of Surgical Antimicrobial Prophylaxis Practices in Australia

Surgical antimicrobial prophylaxis (SAP) is a common indication for antibiotic use in hospitals and is associated with high rates of inappropriateness. To describe the SAP prescribing practices and assess hospital, surgical, and patient factors associated with appropriate SAP prescribing. Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey audits from January 1, 2016, to June 30, 2018. Data were analyzed using multivariable logistic regression. Crude estimates of appropriateness were adjusted for factors included in the model by calculating estimated marginal means and presented as adjusted-appropriateness with 95% confidence intervals. Adjusted appropriateness and factors associated with inappropriate prescriptions. A total of 9351 surgical episodes and 15 395 prescriptions (10 740 procedural and 4655 postprocedural) were analyzed. Crude appropriateness of total prescriptions was 48.7% (7492 prescriptions). The adjusted appropriateness of each surgical procedure group was low for procedural SAP, ranging from 33.7% (95% CI, 26.3%-41.2%) for dentoalveolar surgery to 68.9% (95% CI, 63.2%-74.5%) for neurosurgery. The adjusted appropriateness of postprocedural prescriptions was also low, ranging from 21.5% (95% CI, 13.4%-29.7%) for breast surgery to 58.7% (95% CI, 47.9%-69.4%) for ophthalmological procedures. The most common reason for inappropriate procedural SAP was incorrect timing (44.9%), while duration greater than 24 hours was the most common reason for inappropriate postprocedural SAP (54.3%). High rates of inappropriate procedural and postprocedural antimicrobial use were demonstrated across all surgical specialties. Reasons for inappropriateness, such as timing and duration, varied according to the type of SAP and surgical specialty. These findings highlight the need for improvement in SAP prescribing and suggest potential targeted areas for action.

Antibiotic appropriateness and guideline adherence in hospitalized children: results of a nationwide study.

Information on the nature and appropriateness of antibiotic prescribing for children in hospitals is important, but scarce. To analyse antimicrobial prescribing and appropriateness, and guideline adherence, in hospitalized children across Australia. We analysed data from the National Antimicrobial Prescribing Survey (NAPS) from 2014 to 2017. Surveys were performed in hospital facilities of all types (public and private; major city, regional and remote). Participants were admitted children <18 years old. Risk factors associated with inappropriate prescribing were explored using logistic regression models. Among 6219 prescriptions for 3715 children in 253 facilities, 19.6% of prescriptions were deemed inappropriate. Risk factors for inappropriate prescribing included non-tertiary paediatric hospital admission [OR 1.37 (95% CI 1.20-1.55)] and non-major city hospital location [OR 1.52 (95% CI 1.30-1.77)]. Prescriptions for neonates, immunocompromised children and those admitted to an ICU were less frequently inappropriate. If a restricted antimicrobial was prescribed and not approved, the prescription was more likely to be inappropriate [OR 12.9 (95% CI 8.4-19.8)]. Surgical prophylaxis was inappropriate in 59% of prescriptions. Inappropriate antimicrobial prescribing in children was linked to specific risk factors identified here, presenting opportunities for targeted interventions to improve prescribing. This information, using a NAPS dataset, allows for analysis of antimicrobial prescribing among different groups of hospitalized children. Further exploration of barriers to appropriate prescribing and facilitators of best practice in this population is recommended.

Urinary tract infections in Australian aged care homes: Antibiotic prescribing practices and concordance to national guidelines

Since 2015 the Aged Care National Antimicrobial Prescribing Survey has collected and reported data on antibiotic use in Australian aged care homes (ACHs) as part of the Australian Commission on Safety and Quality in Health Care's Antimicrobial Use and Resistance in Australia project. The objective of this study was to analyze this data source with regards to prescribing for urinary tract infections (UTIs) to improve the use of antibiotics. This cross-sectional study analyzed the 2016 and 2017 survey data. Antibiotic prescribing for urinary tract indications was compared with national guideline recommendations. A total of 662 antibiotic prescriptions from 247 ACHs were analyzed. For all prophylactic antibiotics for UTI, 51.8% were prescribed for longer than 6 months, contrary to the guideline recommendation. Most antibiotics prescribed for treatment (71.6%) were for cystitis. Cefalexin was most frequently selected for treatment of cystitis, with 10.4% of these prescriptions being concordant with the recommendations. Prescribing additional daily doses of cefalexin occurred in 63.2% of prescriptions. Antimicrobial stewardship activities targeting UTI prophylaxis for durations longer than 6 months, and excessive daily doses of cefalexin to treat cystitis could yield significant reductions in unnecessary antibiotic consumption among Australian residents of ACHs.